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JEMS Editor-in-Chief Comments on Orthopaedic Research Findings


A.J. Heightman, JEMS Editor-in-Chief:
This week, the 2012 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) is taking place at the Moscone Convention Center in San Francisco. Several research reports being presented to the attendees are very applicable to EMS and worthy of being passed along.

Economic Factors Impact Orthopaedic Trauma Volume
Orthopaedic trauma cases decline in weak economy

Previous studies have found that human behavior during a recession is remarkably different than that during a bullish economy. For example, people tend to spend more time focused on working and less time engaging in leisure and recreation activities, resulting in fewer motor vehicle and other accidents.

According to a 10-year study at a Level 1 regional trauma center, economic trends do impact orthopaedic trauma volume.  Between 1999 and 2009, a local county's population steadily grew at an annual rate between .9 and 2.9 percent. Unemployment rates peaked in 2002 at 5.4 percent, declined to 3.3 percent in 2006, and rose again in 2009 to 10.7 percent.

While general trauma volume increased during the later years, there was a significant negative association between orthopaedic trauma volume and county unemployment rates of the previous year. 

EMS MESSAGE:  EMS crews should expect that, as the economy declines. They may see less orthopaedic trauma caused by recreational incidents, but an increase in injuries that result from crime and violence associated with the desperation of individuals seeking money from any source in a down econmy.

Modern, Low-Energy Ammunition Can Cause Deep Tissue Damage

Orthopaedic surgeons (and EMS crews) should pay close attention to handgun injuries, provide aggressive care when needed

Gunshot injuries are typically categorized as low- or high-energy based on the weapon's missile velocity and mass. Typically, low energy injuries are treated with simple wound care, with or without antibiotics, regardless of the presence of a fracture. In contrast, high energy injuries are treated more aggressively. 

However, modern low-energy handgun ammunition is designed to inflict significant soft tissue damage, which can cause infection and compartment syndrome (a painful condition that occurs when pressure within the muscles builds to dangerous levels).

A review of ballistics data from forensic scientists and law enforcement officers in a major U.S. city police department, as well as gunshot-induced fractures from a single level 1 trauma center, found that low-energy handgun injuries have become more prevalent, and with hollow point ammunition (designed to expand when entering the body), can cause severe underlying tissue injury that may be overlooked by clinicians. 

Orthopaedic surgeons need to be aware of this powerful new ammunition, and the likelihood that even "low energy" handguns can cause substantial bone and soft tissue injury.

EMS MESSAGE:  Because "low energy" handguns can cause substantial bone and soft tissue injury, EMS crews should not assume that wounds inflicted by a small caliber, perhaps found at the scene, will be insignificant and should be assessed and treated aggressively, with consideration of transport to a trauma center.

Risk of Pulmonary Embolism (PE) Greatest During First Week Following Total Joint Replacement
Prolonged use of therapies to minimize blood clot risk may be unnecessary

The elevated risk of pulmonary embolism (PE) – a blood clot that travels from the leg to the lungs – has been well established, yet little is known about the natural course and timing of this potentially fatal condition.

The records of 25,660 patients who received total joint replacement (TJR) between 2000 and 2010 were reviewed. All patients received the anticoagulation (blood thinning) drug Coumadin immediately following surgery and each was monitored, but not screened, for PE.

Pulmonary embolisms that  occurred within 90 days of the joint replacement was documented.
The median occurrence of PE was two days following surgery, with 254 out of 286 cases of PE (88.8 percent) occurring within the first seven days after surgery.  Based on the findings of this study, anticoagulation treatment beyond seven days may not be necessary.

EMS MESSAGE:  While the message for orthopaedic surgeons is that most PEs (89%) occur within the seven day period immediately following a patient’s surgery and allow them to be taken off Coumadin sooner in the future, there is an important assessment and history fact presented in these results for emergency response crews. That message is that EMS crews that respond to respiratory distress cases in patients within the first seven days after a total joint replacement (TJR) should be highly suspicious of pulmonary embolisms (PEs). 

Content source: PR Newswire on behalf of the AAOS


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